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General NPI Number Information
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NPI Number | 1053532580
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Entity Type | Organization
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Legal Business Name | JASON K BOUTROS M D INC
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Dates
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Enumeration Date | 05/01/2007
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Last Update Date | 01/28/2011
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Provider Practice Location Address
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Address Line | 2750 E WASHINGTON BLVD SUITE 260
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City | PASADENA
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State | CA
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Zip | 91107-1448
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Country | US
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Telephone | 626-798-8923
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Fax | 626-798-0258
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Provider Business Mailing Address
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Address Line | 2750 E WASHINGTON BLVD SUITE 260
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City | PASADENA
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State | CA
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Zip | 91107-1448
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Country | US
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Telephone | 626-798-8923
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Fax | 626-798-0258
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | CINDY CHON
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Credential |
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Telephone | 626-798-8923
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | A42891
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License Number State | CA
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